REMEMBER

• THESE SLIDES ARE EXAMPLES TO GIVE A

BETTER IDEA ABOUT PHYSIOLOGY SPOTTING
EXAMINATION.
• THESE SLIDES ARE NOT A SUGGESTIVE SETS
(DIAGRAM & QUESTIONS MAY VARY).
• SO, PREPARE YOUR SPOTTERS WITH
QUESTIONS BY DIFFERENT ANGLE OF VIEW AS
MAXIMUM AS POSSIBLE.
GENERAL PHYSIOLOGY
 Homeostasis
why is life threatning in + feedback

A vicious circle (or cycle) is a complex chain of events that reinforces

itself through a feedback loop, with detrimental results.
Gain of a Control System. The degree of effectiveness with which a
control system maintains constant conditions is determined by the
gain of negative feedback.
Cell membrane
Intercellular connections
Tonicity
Effect of concentration of
substance on rate of diffusion in
simple and facilitated diffusion
Active transport
Co-transport and counter-
transport
Action potential
Cardiac and nerve AP
Refractory period
Musculo skeletal system
 The optimal resting length is the length at which the
muscle produces the maximal isometric twitch force.
 The graduated series of increasingly vigorous contractions that
results when a corresponding series of identical stimuli is applied
to a rested muscle called also staircase effect, staircase
phenomenon

A tetanic contraction (also called tetanized state, tetanus, or physiologic

tetanus, the latter to differentiate from the disease called tetanus) is a
sustained muscle contraction[2] evoked when the motor nerve that innervates
a skeletal muscle emits action potentials at a very high rate.
When two successive stimuli are applied to the muscle in such a way that the
second stimulus falls after the relaxation period of the first curve, two
separate curves are obtained and the force of second contraction is greater
than that of first one. This is called beneficial effect.
 Sarcoglycanopathies are a group of
autosomal recessive muscle-wasting
disorder
NEUROSENSORY SYSTEM
•Which reflex test elicited hare? 0.5
•Identify the normal and abnormal response from A & B. 0.5
•Write two features of UMNL.
•What is Jendrassik maneuver 1
UMNL
HYPER-REFLEXIA, BABISKI SIGN+
• BABINSKI SIGN POSITIVE
• SLEEP, IN INFANTS
•
LAT. SPINOTHALAMIC TRACT
LEFT SIDE
•Identify the structure. 0.5
•Write the three functional divisions marked A, B, C. 3X 0.25
•Write one function each of these divisions A, B, C 3X 0.25
Aphasia is an impairment of language, affecting the Dyslexia is a learning disorder that involves difficulty reading due
production or comprehension of speech and the ability to to problems identifying speech sounds and learning how they relate
read or write. Aphasia is always due to injury to the brain- to letters and words (decoding). Also called reading disability, dyslexia
most commonly from a stroke, particularly in older affects areas of the brain that process language.
individuals.

Dyscalculia is a math learning disability that impairs an individual's

ability to learn number-related concepts

Apraxia is a neurological disorder characterized by the inability to
perform learned (familiar) movements on command, even though the
command is understood and there is a willingness to perform the
movement. Both the desire and the capacity to move are present but
the person simply cannot execute the act.
Dysgraphia is a neurological disorder of written
expression that impairs writing ability and fine motor skills.
It is a learning disability that affects children and adults,
and interferes with practically all aspects of the writing
process, including spelling, legibility, word spacing and
sizing, and expression
•What is Homunculus? 1
•Identify the homunculus A & B. 1
•Which body part has the largest
representation in the somatosensory map?
•Identify the clinical sign A & B. 1
•What are the causes. 1
•Identify the structure A & B. 1
•Write the functions of amygdala. 1
1
• Basal ganglia and its lesion
CRANIAL NERVE
•Identify the cranial nerves A, B, G, & K. 1

•Which cranial nerve is the largest one and mention its two functions? 0.5+0.5
CRANIAL NERVES I.Olfactory CEREBRAL
II.Optic HEMISPHERE
III.Oculomotor
IV.Trochlear MIDBRAIN

V.Trigeminal
VI.Abducens
PONS
VII.Facial
VIII. Vestibulo-
cochlear

MEDULLA
IX Glossopharyngeal
X Vagus
XI Accessory
XII Hypoglossal
2
CRANIAL NERVES
 REMEMBER M E …
SOME
SAYS
S-SENSORY
MONEY M- MOTOR
MATTERS
BUT B- BOTH
MY
BROTHER
SAYS All in
BIG
BUDGET
sequence
MATTERS
MORE
4
CRANIAL NERVES
 CN I - OLFACTORY
• ORIGIN: Cerebral hemisphere
• INNERVATION: Nasal mucous
membranes.
• FUNCTION: Sense of smell
• DYSFUNCTION: Anosmia

CLINICAL EVALUATION
• Use non-noxious aromatic
substances, i.e. coffee, lemon,
garlic, etc.
• Test each nostril separately.
• Mark if any abnormality noted

5
CRANIAL NERVES
 CN II – OPTIC NERVE
• VISUAL ACUITY: Snellen
chart for distant vision,
Jaegers chart, newspaper or
fingers for near vision.

• VISUAL FIELDS:
Confrontation.

• FUNDI AND OPTIC DISCS:

Visualization of the termination
of the optic nerve by looking
through pupil with
ophthalmoscope.

CRANIAL NERVES 6
CN II – OPTIC NERVE(cont..)
Tested by-
1. Visual acuity

2. Color vision

3. Visual field

7
CRANIAL NERVES
 CN II – OPTIC NERVE(cont..)
Visual acuity-
Snellen chart(Far vision)
◦ Chart is placed at 20 feet or 6
meter and patient is asked to
read it
◦ The formula is d/D
Where d is 6 meter and D is
the distance from which he can
read it clearly
Normal is 6/6 or 20/20
Jaegers chart(Near vision)
◦ Paragraphs are printed in
successive coarser type with
0 is finest and 7 is biggest
◦ Patient is asked to read
through the hole

8
CRANIAL NERVES
 CN II – OPTIC NERVE(cont..)
Color vision-
◦ Checked by asking to
match different colors
• Day or night blindness
can be assessed

• Visual field-
Confrontation test

Peripheral visual fields-

Goldmann Perimeter

CRANIAL NERVES 9
People with ‘faulty’ trichromatic vision will be colour blind to some extent and are
known as anomalous trichromats. In people with this condition all of their three
cone types are used to perceive light colours but one type of cone perceives light
slightly out of alignment,

The different anomalous conditions are protanomaly, which is a reduced

sensitivity to red light, deuteranomaly which is a reduced sensitivity to green
light and is the most common form of colour blindness and tritanomaly which is
a reduced sensitivity to blue light and is extremely rare.
Two Ishihara charts. In this chart (upper panel), a
person with normal vision reads “74,” but
a red-green color-blind person reads “21.”

In this chart (lower panel), a red-blind person

(protanope) reads “2,” but a green-blind person
(deuteranope) reads “4.” A person with normal
vision reads “42.”
 SPECIFIC DYSFUNCTIONS
• Blurred vision or complete blindness.
• Ipsilateral vision loss - Optic atrophy, retinal/optic
nerve lesions, trauma.
• Visual loss (one or both eyes) - Optic chiasm or
occipital lobe lesions.
• Hemianopia - (loss of half of visual field in one or
both eyes) - Lesions of optic chiasm, tracts, or
radiations.
• Cortical blindness - Lesion of occipital cortex
bilaterally, pupil reflexes intact.
• Papilledema - Optic nerve tumor, venous
obstruction, chronic increased ICP.
• Optic atrophy - MS, optic neuritis, increased ICP.
• Scotomas- (Abnormal blind spots on visual fields)
- optic neuritis or atrophy.

10
CRANIAL NERVES
CN III – OCULOMOTOR NERVE
ORIGIN: Midbrain
INNERVATION: EOM's;
eyelid; ciliary; and sphincter of
iris.
FUNCTION: Eye movement
inward (medially), upward,
downward, and outward; pupil
Constriction, shape and
equality; elevates upper eyelid;
accommodation reflex.
DYSFUNCTION: Unable to
look up, down, or medial
(dysconjugate gaze); ptosis,
pupil dilatation - bilateral or
ipsilateral, and loss of
accommodation reflex.
CRANIAL NERVES
11
 CN III – OCULOMOTOR
NERVE(cont..)
• Observe for eye opening and
symmetry.

• Direct light response - brisk,

sluggish, or non-reactive.

• Consensual response -
present or absent.

• Pupil size and shape.

• Accommodation.

• Extra ocular movement

(EOM's) (Abducens).
CRANIAL NERVES 12
 CRANIAL NERVE FUNCTION & MUSCLE
INNERVATION
RELATIVE TO EYE MOVEMENT
Superior rectus Inferior oblique
CN III CN III

Lateral rectus Medial rectus

CN VI CN III

Inferior rectus
Superior oblique
CN III
CN IV
CN IV – TROCHLEAR NERVE
ORIGIN: Midbrain
INNERVATION: Superior
oblique muscle.
FUNCTION: Down and
inward movement of the
eye.
DYSFUNCTION: Loss of
downward, inner
movement of eye,
dysconjugate gaze.

SUPERIOR OBLIQUE MUSCLE

CRANIAL NERVES 14
CN VI – ABDUCENS NERVE
ORIGIN: Pons
INNERVATION: Lateral
rectus muscle.
FUNCTION: Outward,
lateral movement of eye.
DYSFUNCTION: Loss of
lateral eye movement,
dysconjugate gaze.
LATERAL RECTUS
MUSCLE
Clinical evaluation of CN III, IV, VI
•Extraocular movements (EOM's)

•CN IV (Trochlear) and CN VI tested with CN III (Oculomotor)

CRANIAL NERVES 15
1 Identify the type of paralytic strabismus in this girl child. Which cranial
nerve defect may create this condition? 0.75+0.75
2 Write one cause of non-paralytic concomitant squint of vision.
0.5
• LATERAL RECTUS
• VI
•Mention the name of the Pupillary muscles labeled A & B.
1
•Mention their nerve supply. 1
CN V – TRIGEMINAL NERVE
ORIGIN: Pons. The sensory
nucleus extends from the
pons to the midbrain, and also
to the medulla and spinal
cord.
INNERVATION: Three
branches of CN V:
Ophthalmic, maxillary, &
mandibular.
Motor innervation to
masseter & temporal
muscles.
Sensory innervation to skin &
mucous membranes in head;
teeth, tongue, external
auditory canal, and cornea.
16
CRANIAL NERVES
CN V – TRIGEMINAL NERVE(cont..)
FUNCTION: Sensation of
pain, touch, hot, & cold; motor
movement of masseter &
temporal muscles.
DYSFUNCTION: Loss of
sensation - if affecting all
three branches, indicative of
peripheral injury.
Brainstem or upper cervical
cord injury may result in loss
of sensation to one or more
branches of the trigeminal
nerve.
Loss of corneal reflex.

17
CRANIAL NERVES
CN V – TRIGEMINAL NERVE(cont..)
Paresthesia and/or severe
pain indicative of nerve
compression or irritation
(Trigeminal neuralgia)
Deviation of jaw towards the
same side, loss of sensation.
Inability to bite down and
chew, inability to close jaw.
Chewing, speaking, washing
face, cold water, may
precipitate the
attack…TRIGGER POINT

18
CRANIAL NERVES
 CN V – TRIGEMINAL
NERVE(cont..)
Tic douloureux or
trigeminal neuralgia
Paroxysmal attacks of
severe, short, sharp, stabbing
pain affecting one or more
branch of the nerve.
Most excruciating pain
known (?)
Caused by inflammation of
nerve
In severe cases, nerve is cut;
relieves agony but results in
loss of sensation on that side
of the face

CRANIAL NERVES 19
 TESTING TRIGEMINAL NERVE
o Sensation-
o Checked by extroceptive
modalities like superficial pain,
thermal, light touch over jaw,
cheeks, and forehead.
o Motor examination-
o Muscle power of masticatory
muscle namely the masseter
and temporalis.
o Inability to raise, depress,
protrude, retract and deviate
the mandible
o Jaw deflected toward same
side

20
CRANIAL NERVES
 TESTING TRIGEMINAL NERVE
Jaw jerk-
o Ask the patient to relax
jaw. Place finger on the
chin and tap it with
hammer.
o closing of mouth is the
response
o Brisk is normal
o Exaggerated is
pathological
◦ Corneal reflex-
o Cornea is touched with wisp
of wet cotton
o Response is closing of both
eyes
o Afferent- ophthalmic div of
VI nerve
21
o Efferent- Facial nerve CRANIAL NERVES
 CN VII- FACIAL NERVE
ORIGIN: Pons & medulla.
INNERVATION: Anterior
two-thirds of tongue; facial
muscles, scalp, ear, and
neck.
FUNCTION:
Control of facial muscles
(expressions)
Motor limb of blink &
corneal reflex
Secretion of salivary &
lacrimal glands
Sensation of taste, anterior
two-thirds tongue.

22
CRANIAL NERVES
 Motor-
◦ Facial asymmetry - Ipsilateral weakness/paralysis, right or left,
indicative of damage to motor nucleus or peripheral component
(lower motor neuron lesion) EX: Bell's palsy
◦ Contralateral weakness/paralysis of lower face indicative of
Contralateral motor cortex damage (upper motor neuron lesion)
or hemispheric lesion, i.e. massive CVA.
◦ Bilateral weakness or paralysis , E.g. myasthenia gravis or
Guillian Barre.
Parasympathetic-
◦ Loss or excessive tearing or salivation
• Sensory-
◦ Loss of taste from anterior 2/3
Combined problem-
◦ speech difficulty and drooling/difficulty handling food

23
CRANIAL NERVES
 CLINICAL EVALUATION
o MOTOR FUNCTION:
o Observe for facial symmetry
o Flattening of nasolabial fold
o Ask patient to wrinkle
forehead, puff cheeks, smile,
show teeth, close eyes
against resistance, and
whistle.
o Wrinkle forehead- Frontalis
o Close eye- orbi oculi
o Purse lip- Buccinator
o Show teeth- Orbi oris

24
CRANIAL NERVES
 CN VII- FACIAL NERVE(cont..)
SENSORY FUNCTION:
• Test each side of tongue
separately.
• Test for sweet (tip of
tongue); sour (sides of
tongue); salty (over most of
tongue, but concentrated on
sides).
• Give sip of water.
• Prevent flowing it to the
posterior aspect of tongue
• Reflex-
• Corneal reflex
• Glabellar reflex- Parkinson's
disease

25
CRANIAL NERVES
 BELLS PALSY
• Bell’s palsy: paralysis of
facial muscles on affected
side and loss of taste
sensation
• Caused by herpes simplex
I virus, trauma,
• Lower eyelid droops
• Corner of mouth sags
• Eye cannot be completely
closed (dry eye may occur)
• Lacrimation is seldom
affected
• Condition may disappear
spontaneously without
treatment
Bells phenomenon-
Upward and outward
movement of eye
27
CN VII- FACIAL NERVE(cont..)

CRANIAL NERVES 26
CN VIII – VESTIBULOCOCHLEAR
NERVE
ORIGIN: Pons and medulla
INNERVATION:
◦ Cochlear - ear
◦ Vestibular - ear
FUNCTION:
◦ Cochlear - Hearing
◦ Vestibular - Balance,
maintenance of body
position, and proprioception.
◦ Rule out for presence of
wax, pus, blood or foreign
body Before testing

28
CRANIAL NERVES
 COCHLEAR NERVE
Rinne’s test-
◦ For comparing bone and ai r
conduction
◦ Tuning fork placed at the
mastoid till the sound stop
being heard
◦ Then is placed in front of
ear to be tested
◦ +ve Rinne test i.e. air and
bone both are retained
◦ -ve Rinne test i.e. air is lost
but bone is
retained(conductive
deafness)
◦ If both are lost i.e.
sensorineural deafness
◦ BERA TEST CRANIAL NERVES
29
 COCHLEAR NERVE(cont..)
Weber's test-
◦ Evaluates lateralization
◦ Use vibrating tuning fork on
top of patient's head, ask
patient where he hears it
(one or both sides).
◦ Normally heard equally on
both the sides
◦ If one ear is occluded then
it acts like a resonating
chamber and hear more on
that side
◦ Conductive deafness-
involved side
◦ Sensorineural- Uninvolved
side

30
CRANIAL NERVES
 VESTIBULAR NERVE
Look for Vertigo,
Nystagmus, loss of balance
NYLEN-BARANY
MANEUVER
◦ Patient lie down supine
with head off the bed
◦ 45 degree extended
◦ Lateral flexion to the
same side produces
Nystagmus
• Other tests are
• caloric test (cows)
• Galvanic test
• Rotation test
31
CRANIAL NERVES
CN VIII – VESTIBULOCOCHLEAR
NERVE
DYSFUNCTION (Cochlear)
◦ Unilateral deafness
◦ Loss of sound appreciation
◦ Tinnitus
◦ (Rinne Test) AC >BC is
normal
◦ both diminished
indicative of nerve
damage
◦ BC> AC middle ear
disease.
◦ (Weber Test)
◦ Lateralization to good
ear is nerve damage,
◦ lateralization to bad
ear is, middle ear
CRANIAL NERVES 32
disease
CN VIII – VESTIBULOCOCHLEAR
NERVE
DYSFUNCTION
(VESTIBULAR)
◦ Vertigo
◦ Balance disturbances
Vestibular branch normally
not tested unless patient
gives history of vertigo or
balance Disturbance
history is positive, caloric
testing is done by
physician.

CRANIAL NERVES 33
• In clinical practice, the 512-Hz tuning fork has
traditionally been preferred. At this frequency, it
provides the best balance of time of tone decay and
tactile vibration.
• Lower-frequency tuning forks like the 256-Hz tuning
fork provide greater tactile vibration. In other words,
they are better felt than heard.
•Write the test name & cranial nerve which you are examining. 1
•Mention the area where you have to touch base of the tuning fork. 0.5
•How much HZ tuning fork you have to use in this test. 0.5
 CN IX- GLOSSOPHARYNGEAL
NERVE
ORIGIN-
◦ Medulla
INNERVATION:
◦ Mucous membranes of
tonsils, pharynx, posterior
one-third of tongue,
pharyngeal muscles,
carotid sinus and carotid
body
FUNCTION:
◦ Taste from posterior one-
third of tongue - Afferent
limb of gag, swallow, and
cardiac reflexes.
• DYSFUNCTION:
◦ Loss of taste; Neuralgia

34
CRANIAL NERVES
 ORIGIN-
CN X – VAGUS NERVE
◦ Medulla
INNERVATION:
◦ Muscles of larynx, pharynx, and
soft palate.
◦ Parasympathetic innervation of
thoracic and abdominal viscera.
FUNCTION:
◦ Muscles of larynx, pharynx, and
soft palate
◦ Sensation conveyed from the
heart, lungs, digestive tract,
carotid sinus, & carotid body
◦ Efferent limb of gag and swallow
reflex
• DYSFUNCTION:
• Loss of gag & swallow reflex
• Loss of carotid sinus
CRANIAL NERVES 35
• oculocardiac reflex; Dysphagia
 CN IX- GLOSSOPHARYNGEAL
and CN X - VAGUS
CN IX and X considered jointly, actions are seldom compared separately; they a

POSSITIVE FINDINGS-
Evaluate voice quality
(hoarseness or dysarthria)
Ask patient to open mouth, say "ah", observe for elevation of
soft palate, midline position of uvula.
Gag reflex, bilaterally
Swallowing
Taste (bitter) posterior one-
third tongue

CRANIAL NERVES 36
CN IX- GLOSSOPHARYNGEAL
and CN X - VAGUS
Negative Findings
Loss of voice quality,
(dysarthria or hoarseness)

Deviation of uvula toward

non-paralyzed side

Swallowing difficulty or
nasal regurgitation

Vagal irritation
(bradycardia)

CRANIAL NERVES 37
CN XI - SPINAL ACCESSORY
NERVE
ORIGIN: Medulla
INNERVATION:
Sternocleidomastoid &
trapezius muscles
FUNCTION: Motor
function
Sternocleidomastoid &
trapezius
DYSFUNCTION: Muscle
weakness.

CRANIAL NERVES 38
 CN XI - SPINAL ACCESSORY
NERVE
• CLINICAL EVALUATION
• Palpate trapezius muscle as
patient shrugs shoulders
against resistance; evaluate
strength.
• Ask patient to turn head to
one side and push against
examiners hand or ask to flex
head against resistance,
palpate and evaluate strength
of sternocleidomastoid
muscle.
• Evaluate both right and left
side, compare for symmetry.

39
CRANIAL NERVES
 CN XII –HYPOGLOSSAL
ORIGIN: Medulla
NERVE
INNERVATION: Muscles of the
tongue except palatoglossus
FUNCTION: Movement of the
tongue
DYSFUNCTION:
◦ Unilateral lesions can cause
paresis, atrophy, furrowing,
fibrillation and fasciculation on
the affected half
◦ On protrusion tongue deviates
towards the affected side due to
unopposed action of the
Contralateral GENIOGLOSSUS

Flaccid paralysis
◦ Dysphagia
◦ Dysarthria
◦ Dyspnea
◦ Difficulty chewing food
40
CRANIAL NERVES